Download Identification and treatment of eating disorders in people with

R EVIEW
Identification and treatment of eating disorders
in people with obsessive–compulsive disorder
Joanna E Steinglass
Department of Psychiatry,
Columbia University College
of Physicians & Surgeons,
Eating Disorders Research
Unit, New York State
Psychiatric Institute,
1051 Riverside Drive,
New York, NY 10032, USA
Tel.: +1 212 543 6742;
Fax: +1 212 543 5607;
E-mail: js1124@
columbia.edu
Keywords: anorexia nervosa,
bulimia nervosa, eating
disorder, obsessive–compulsive
disorder, treatment
part of
Patients with obsessive–compulsive disorder (OCD) commonly struggle with an eating
disorder as well, which raises several issues for treatment providers. First and foremost,
the patient who is seeking treatment for OCD may not have identified or disclosed the
presence of an eating disorder, leaving it to the clinician to accurately assess these
diagnoses. Diagnosis of an eating disorder in a patient with OCD follows the same
guidelines as diagnosis in a patient without OCD. The assessment may be complicated by
the patient’s lack of insight or ambivalence regarding treatment for the eating disorder
(as distinguished from the treatment for OCD). Treatment of OCD can be complicated by
the presence of an eating disorder. Patients with anorexia nervosa may not respond to
pharmacologic interventions. Malnourishment in patients with anorexia nervosa or
bulimia nervosa may impair the patient’s participation in psychotherapy for OCD.
Clinicians treating patients with OCD need to be adept at diagnosing eating disorders in
this population, and will need to consider the role of the eating disorder when
planning treatment.
Obsessive–compulsive disorder (OCD) is a
common and disabling illness. Reported prevalence rates vary, but lifetime prevalence has been
estimated at 2% [1]. The symptoms involve a
combination of dysfunctional thoughts and
behaviors. The obsessions of OCD are persistent
thoughts, impulses or images that are intrusive
or unwanted. Compulsions are repetitive, purposeful actions that are usually intended to neutralize or reduce the anxiety raised by the
obsessions. Such compulsions are highly ritualized and stereotyped behaviors. The patient has
some degree of insight that his/her worries are
unrealistic; however, insight in OCD occurs
along a spectrum and can be so limited that
patients seem delusional [2]. Patients with OCD
often have coexisting psychiatric disorders,
which can complicate the clinical picture. In
particular, there is a high degree of comorbidity
with eating disorders [3]. There are phenomenologic similarities between eating disorders and
OCD such that the eating disorder diagnosis can
be missed in a patient who presents for treatment of OCD. Furthermore, the presence of an
eating disorder raises several issues complicating
the patient’s treatment. This paper aims to provide clinicians treating patients with OCD with
a review of the issues that are important in the
evaluation and treatment of eating disorders.
Eating disorders encompass a seemingly disparate group of illnesses in terms of behavior
and appearance. Anorexia nervosa (AN) is
10.1586/14750708.4.4.473 © 2007 Future Medicine Ltd ISSN 1475-0708
characterized by a relentless pursuit of thinness
and fear of becoming fat, in which patients
starve themselves to the extremes of low
weight, resulting in amenorrhea and risk of
death. Bulimia nervosa (BN) appears somewhat
different in that patients are of normal weight
but engage in recurrent binge eating and compensatory behaviors, such as vomiting, compulsive exercise or laxative abuse. These behaviors
also pose significant health risks; complications
of BN can result in a range of morbidities, from
relatively minor dental caries to the more significant cardiac arrhythmias and esophageal
tears. Binge-eating disorder (BED) is characterized by episodes of excessive intake, with a
sense of loss of control and without compensatory behaviors, which frequently results in
obesity (although this is not a diagnostic criterion). Collectively, eating disorders are characterized by excessive concerns with shape and
weight, and abnormal eating behaviors.
Comorbidity between OCD &
eating disorders
Many studies have suggested a notable degree
of comorbidity between OCD and eating disorders [4]. In patients with a primary diagnosis
of OCD, lifetime prevalence of an eating disorder has been reported to be 10.2% (3.1% with
AN, 3.1% with BN, 1.4% with BED and 3.1%
with eating disorder not otherwise specified
[EDNOS]) [5]. One study of heritability of
Therapy (2007) 4(4), 473–479
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OCD and eating disorders found that OCD
spectrum disorders were significantly more
common in first-degree relatives of patients
with eating disorders (AN and BN) [6].
Rates of OCD in patients with a primary eating disorder vary. Comorbidity with OCD has
consistently been reported to be higher in AN
than in BN [7,8] yet comorbidity in BN is also
more common than in healthy controls [8].
Halmi and colleagues reported that, out of 62
patients with AN, a quarter had a lifetime history
of OCD [9]. In a much larger sample of inpatients and outpatients with AN, Godart and colleagues similarly reported a lifetime prevalence of
OCD in approximately 25% of patients [10],
which is significantly greater than in a matched
control population. A review of the literature on
comorbidity in AN reported that in patients with
AN, the lifetime prevalence of OCD ranged
from 10–66%, and prevalence was higher than in
a control group [11]. Comorbidity between BED
and OCD has not been well studied; however,
the one small study in this area suggests that
OCD is not more common in patients with
BED, and that OCD symptoms in obese
patients with BED are comparable to obese nonbinge-eating patients and are significantly lower
than patients with OCD [12].
While the rate of comorbidity may be overrepresented in these studies involving clinical
cohorts, the consistent findings of coexistence
of these disorders suggests that patients who
present with OCD should be assessed for the
presence of an eating disorder. While eating disorders are more commonly seen in women, they
are not exclusive to women; therefore, heightened awareness of the possibility of an eating
disorder is warranted for both sexes. Those who
provide treatment for OCD need an understanding of the assessment and treatment of
eating disorders.
Biological overlap between OCD &
eating disorders
Several lines of evidence suggest that there may
be biological commonalities between OCD and
eating disorders. Data from a large study of the
genetics of AN and BN have suggested that perfectionism is a personality trait that coaggregates
with obsessive–compulsive personality disorder,
OCD and eating disorders [13]. Thus, it may be
that there is a genetic shared vulnerability to
OCD and AN. Cognitive neuroscience research
has noted similar deficits on neuropsychological
tasks in patients with AN and OCD [14,15]. The
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Therapy (2007) 4(4)
tasks administered in these studies implicate
abnormalities in frontostriatal circuits, which
are proposed to subserve the pathology of OCD
in one prominent model [16,17]. Interestingly,
there are case reports of AN triggered by infections (group A β-hemolytic streptococcus,
Epstein–Barr and upper respiratory infections),
which has been described as ‘autoimmune AN’,
similar to reports of postinfectious OCD [18–20].
Disturbances in CNS serotonin function have
also been implicated in both disorders [21,22].
These observations provide circumstantial evidence that OCD and AN may share a common
neurobiological foundation.
Making the diagnosis
Both OCD and eating disorders involve a combination of obsessive thoughts and stereotyped
behaviors. Patients who present for treatment of
OCD need to be asked whether they have any
symptoms relating to food, or shape and weight.
When obsessions and compulsions are food- or
body image-related, the diagnosis of an eating
disorder needs to be considered. The presentation of eating disorders can vary and can comprise a range of symptoms, including behavioral,
psychological and medical. The evaluation of an
eating disorder can be complicated because
patients’ descriptions of their symptoms may
not directly map onto the diagnostic criteria in
the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV) [23]. For
example, a patient is not likely to state that she
experiences “overconcern with shape and
weight”. Diagnostic assessment is even more
complex in the presence of OCD, where eating
disorder symptoms may not be spontaneously
mentioned by the patient.
In addition, the compromised nutritional
status resulting from the eating disorder may
bring about worsening of OCD symptoms,
thereby masking the primary eating disorder
diagnosis. In the starved state, obsessions and
compulsions worsen. Thus, underweight
patients with AN can appear to have more
severe OCD than is the case after weight restoration. Similarly, patients with BN, although
normal weight, can be malnourished from their
binge–purge behaviors, or from electrolyte
imbalances, which can worsen some of their
psychological symptoms. Appropriate diagnosis
is crucial for treatment; therefore, the clinician
needs to be mindful of the common co-occurrence of these disorders and aware of the criteria
for the diagnosis of eating disorders.
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Identification and treatment of eating disorders in people with OCD – REVIEW
The most prominent criterion for the diagnosis of AN is a significantly low body weight;
the DSM-IV cites less than 85% of ideal body
weight as a guideline, though clinical judgment
is recommended. DSM-IV criteria also include a
fear of gaining weight, a distortion of body
image, and amenorrhea for 3 months. BN is
characterized by repeated episodes of binge eating followed by a compensatory behavior to
avoid weight gain. By definition, patients with
BN are of normal weight (patients who binge
and purge but are significantly underweight are
given the diagnosis of AN, purging subtype).
Like in the diagnosis of AN, the diagnosis of BN
requires the presence of overconcern with body
weight and shape. BED is defined by the presence of recurrent episodes of binge eating
(including an excessive amount of food and a
sense of loss of control over eating) without compensatory behaviors. Binge episodes are characterized by eating rapidly, feeling uncomfortably
full, eating without hunger, and embarrassment
or guilt about eating.
When the patient with OCD endorses foodor shape-related concerns, evaluation for an eating disorder needs to be included in the assessment. The components of the evaluation for an
eating disorder are similar across all diagnoses (a
more detailed discussion of the diagnosis of eating disorders can be found elsewhere [24]).
Patients with eating disorders, and particularly
patients with AN, may be ambivalent about or
uninterested in treatment; therefore, it is important to begin the evaluation with nonjudgmental, open-ended questions, allowing the patient
to express feelings about the evaluation. While
the therapist must maintain a nonconfrontational stance, asking specific, direct questions is
also necessary to get past the patient’s ambivalence about disclosing her symptoms. Frequently, this is best done by inquiring about
specific eating patterns (frequency and content
of all food and drink intake) on a typical day.
Certain typical eating disorder behaviors
require specific attention and direct questions.
The clinician needs to evaluate the degree of
restriction or rules around meals by asking if
there are foods that the patient avoids. Assessment of the occurrence and frequency of binge
eating is necessary. Binge eating is defined in the
DSM-IV as the consumption of an unusually
large amount of food, with associated feelings of
loss of control. It is important to note that
patients with AN may experience small amounts
of food as a binge; therefore, the clinician
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should ask about the content of a binge. The clinician should inquire about occurrence and frequency of purging behaviors. These behaviors
include self-induced vomiting and laxative or
diuretic abuse. Less commonly, patients may
chew and spit out food without swallowing. In
patients with diabetes mellitus, purging can also
occur as insulin omission. The clinician should
also assess the frequency and intensity of exercise and the patient’s commitment to exercise
(i.e., will they forgo other activities in order to
continue exercising).
Weight throughout the patient’s lifetime
(highest and lowest weight) and salient weight
changes are also important in clarifying the possible history of eating disorders other than the
current diagnosis. In female patients, menstrual
history is important. AN is characterized by 3
months of amenorrhea, but BN can also present
with amenorrhea. Absence of menses presents a
significant risk to the patient, including risk
of osteoporosis.
Any assessment of a patient with an eating disorder needs to include a clinician’s measurement
of height and weight. The clinician’s measurement is necessary, as people are known to provide inaccurate estimations of height and weight,
irrespective of the presence of an eating disorder.
Further medical evaluation should be recommended, including pulse and blood pressure,
general medical exam, and laboratory tests (a
review of the medical complications of eating
disorders can be found elsewhere [25]).
Considerations in the diagnosis of AN
Patients’ with AN may demonstrate denial of
symptoms and denial of severity of the problem,
which complicates the evaluation. As with
OCD [26], insight in AN has been described as
occurring along a spectrum, with a subgroup of
patients demonstrating delusional levels of conviction in their disordered beliefs [27]. Patients
who have identified OCD as their problem may
well minimize their food- and shape-related
beliefs and rituals, thereby masking a primary
diagnosis of an eating disorder. Furthermore, it
is common for all patients with AN to deny a
fear of gaining weight in interview, so this diagnostic criterion must be inferred from the
patient’s behavior (i.e., inability to maintain a
normal weight).
Importantly, the patient may be unaware of
the impact of low weight on their obsessions
and compulsions. The association between
starvation and emergence of psychological
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REVIEW – Steinglass
symptoms (e.g., food-related obsessions and
rituals, depression and anxiety) has been well
documented [28]. Weight gain is known to lead
to improvement in these symptoms in patients
with AN [29,30]. The clinician may need to provide psychoeducation to the patient, explaining
that the underweight state exacerbates obsessions and compulsions. Some patients have
nonfood-related obsessions and compulsions,
which may resolve, or significantly improve,
with weight restoration. For this reason, the
diagnosis of OCD may need to be reassessed
after the patient has achieved normal weight.
Treatment
The current mainstays of treatment of eating disorders overlap with the current treatments of
OCD: psychological interventions, including
cognitive therapy, behavioral therapy and
psychopharmacologic interventions, such as
selective serotonin-reuptake inhibitors (SSRIs).
However, treatment of eating disorders can also
include family therapy and nutritional counseling. Treating a patient with OCD and a concurrent eating disorder requires initial
determination of the patient’s nutritional status.
A patient who is nutritionally compromised
presents two major concerns in the treatment of
OCD: the eating disorder, and the level of malnutrition, may be exacerbating OCD symptoms;
and the patient may be too nutritionally compromised to benefit from OCD treatment. In
the first scenario, treatment of the eating disorder may ameliorate the OCD symptoms such
that treatment recommendations with respect to
OCD may change. In the second scenario, the
patient’s response to treatment may be impeded
owing to cognitive impairment, which limits
participation in cognitive–behavioral psychotherapy, or may be biologically altered such that
medications prove ineffective [29].
Presence of both OCD and an eating disorder may have implications for the course of
each illness. Although the data are not entirely
consistent [31], comorbid OCD has been associated with a longer duration of AN and BN [32].
This suggests that the presence of OCD may
have an impact on the patient’s prognosis with
respect to the eating disorder.
Anorexia nervosa
SSRIs are a mainstay of the treatment of OCD.
Owing to the phenomenologic similarities and
the overlap between these disorders, SSRIs were
originally thought to be promising for the
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Therapy (2007) 4(4)
treatment of AN. However, in a randomized,
controlled trial, fluoxetine provided no additional benefit compared with placebo with
respect to weight gain in inpatients with AN. In
addition, while both groups showed significant
improvement in psychological measures (depression, anxiety or body image), there was no difference between medication and placebo [29].
Furthermore, a large trial of weight-restored
outpatients with AN found that fluoxetine provided no additional benefit compared with placebo with respect to relapse prevention in
outpatients receiving cognitive–behavioral therapy (CBT) for relapse prevention [33]. Therefore, there is cause for concern that nutritional
status may compromise psychopharmacologic
treatment of OCD.
Given the disappointing results of pharmacologic interventions across medication classes
(antidepressants, antipsychotics or mood stabilizers) for patients with AN, treatment recommendations rely on psychological interventions.
For underweight patients, these include participation in inpatient or day programs aimed at
weight normalization. After weight normalization, emerging evidence supports the utility of
CBT. One study demonstrated that CBT was
more effective than standard treatment (nutritional counseling) for relapse prevention [34].
CBT for AN differs somewhat from CBT for
OCD in that interventions focus on cognitive
distortions and do not include formal exposure
therapy and response prevention. Many studies
have reported cognitive deficits in underweight
patients, especially related to attention [35].
Therefore, there is cause for concern that
patients would have difficulty participating in
psychotherapy for OCD, as therapy requires
attentional capacity as well as learning, which
may be compromised at low weight.
Treatment for AN is in need of further
developments, as current treatments continue
to yield low response rates and high relapse
rates [36]. Nutritional rehabilitation is a critical
first step in the treatment of all patients with
AN [37], and is especially important when considering treatment for coexisting OCD. As has
been emphasized throughout this review, OCD
symptoms improve with weight gain alone [30].
For severely underweight patients, structured
settings such as inpatient or partial hospital may
be required in order to achieve normal weight.
In these settings, behaviorally based treatments
have been very useful in normalizing weight.
Pharmacologic treatments for weight gain in
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Identification and treatment of eating disorders in people with OCD – REVIEW
AN have been disappointing. While anecdotal
reports of successful treatments have been published, only a small number of randomized,
controlled trials have been conducted. For a
detailed review, see Steinglass and Walsh [38]. All
randomized, controlled trials have indicated
that medications are not helpful in underweight
patients with AN, with respect to mood and
anxiety symptoms in addition to eating disorder
pathology. The absence of definitive medication
treatment highlights a need for improved psychological interventions. There are notable similarities between AN and OCD [39]; therefore,
treatment for AN may be improved by drawing
from current understanding of treatment for
OCD and placing increased emphasis on
behavioral techniques.
One commonly accepted model suggests that
binge eating is a response to restraint and resulting hunger. Patients with BN may exhibit
restraint outside of binge episodes such that
they are experiencing effects of starvation,
although not to the same extent as patients with
AN. In addition, binge eating and purging
behavior can lead to electrolyte disturbances,
which may compromise cognitive function.
Some studies have demonstrated cognitive
impairments in patients with BN, especially
with respect to impulsivity [47]. Thus, in
patients with significant illness, it may be
important to see improvement in binge–purge
behavior before embarking on psychological
treatment for OCD.
Binge eating disorder
Bulimia nervosa
Contrary to the treatment of AN, pharmacological interventions have been useful in the
treatment of BN. Several randomized, controlled trials have demonstrated the benefits of
SSRIs in patients with BN [38]. One large study
demonstrated that fluoxetine 60 mg is of
greater benefit than fluoxetine 20 mg [40], suggesting that, similar to the treatment of OCD,
higher doses are of benefit in this population.
This may simplify the pharmacologic management of comorbid OCD and BN. In addition
to antidepressants, topiramate has also been
shown to be useful [41,42].
The data on the use of antidepressants in the
treatment of BN are convincing in indicating
that fluoxetine is safe and beneficial. While it is
likely that other SSRIs would be effective, only
fluoxetine has been examined in placebo-controlled trials, and should be used in a dose of
60 mg/day. Most patients can be rapidly
titrated to this dose over the course of a week.
Buproprion is not recommended in the treatment of BN because of the risk of seizure [43].
There are consistent indications that medications modestly enhance the benefits of psychological treatment. Psychotherapy trials have
demonstrated that CBT for BN is effective in
reducing binge eating and vomiting episodes,
and is the psychotherapy of choice [44]. Studies
that have combined CBT with antidepressant
medication suggest that there may be an advantage to combined treatment over medication
alone [45].
Patients with BN are, by definition, of normal
weight. Nonetheless, their disordered eating patterns may compromise cognitive function [46].
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Treatment of BED in a patient with OCD is less
complicated than the other eating disorders, as
treatment strategies are not in conflict. Several
medication strategies have shown promise in the
treatment of BED, including antidepressants
and weight-loss medications [48,49]. SSRIs are
generally considered first-line treatment for
binge eating because of their favorable side-effect
profile, although they do not demonstrate an
effect on weight loss. In addition, topiramate has
demonstrated efficacy in decreasing frequency of
binge episodes and in decreasing weight [48].
Topiramate can be combined with SSRIs. Sibutramine has also been shown to be helpful for
BED [50], although combining sibutramine with
other serotonergic antipressants poses a theoretical increased risk of serotonin syndrome. Psychotherapy, including individual and group CBT,
has also been shown to be useful in the treatment
of BED [51].
Conclusion & future perspective
When treating patients with OCD, clinicians
need to be alert to the possible presence of an
eating disorder for several reasons. First, the high
degree of comorbidity between illnesses indicates
that the clinician evaluating a patient with OCD
should specifically inquire, in detail, about
symptoms of an eating disorder. Second, the
presence of AN or BN may complicate the treatment of OCD such that the eating disorder
would need to be addressed and some improvement seen prior to embarking on treatment of
the OCD. For patients with AN, weight restoration may be necessary for psychopharmacologic
and psychotherapeutic interventions to be helpful. Third, the clinician should be aware that
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coexistence of OCD with an eating disorder may
worsen the patient’s prognosis for recovery from
the eating disorder, although study results vary.
There are phenomenologic similarities
between obsessions and compulsions in OCD
and food- and shape-related obsessions and rituals in eating disorders, which suggests a shared
pathophysiology between these disorders. There
may be neurobiologic features in these disorders
that represent a shared vulnerability. Patients
may have a neurologic predisposition toward
obsessive, intrusive ideation and stereotyped
behavioral responses that puts them at risk for
either disorder. Brain imaging research in
patients with eating disorders is needed to evaluate frontostriatal circuits in order to determine
whether these disorders share similar neural
mechanisms with OCD. Treatment innovations
are particularly needed in AN. Given the disappointing results from pharmacologic interventions, new treatments may be improved by
capitalizing on the utility of techniques used in
CBT for OCD that have not been formally
studied in some eating disorder populations,
such as development of exposure therapy and
ritual prevention for patients with AN. Translating from clinical research in anxiety disorders
has potential to improve our understanding of
the mechanism of eating disorders, as well as
identify new pharmacologic approaches, such as
those that are beginning to show promise in
enhancing learning in anxiety disorders [52].
Executive summary
• Patients with obsessive–compulsive disorder (OCD) have high rates of comorbid eating disorders,
including anorexia nervosa and bulimia nervosa.
• The presence of an eating disorder can be masked by the patient’s reluctance to spontaneously
report symptoms; therefore, the clinician needs to actively inquire about specific details regarding
eating behavior.
• Starvation and malnutrition that occurs with both anorexia nervosa and bulimia nervosa can lead to
worsening of obsessions and compulsions in OCD.
• Treatment needs to prioritize normalization of eating behavior, and particularly weight, in order to
best treat the patient’s OCD.
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